Urethritis (Drip, Clap)

CHAPTER 83

Urethritis

(Drip, Clap)

Presentation

A man complains of dysuria, a burning discomfort along the urethra, pruritus of the urethral meatus, and/or a urethral discharge. A copious, thick yellow-green discharge that stains underwear is characteristic of gonorrhea, whereas a thinner mucopurulent or white scant discharge with milder symptoms is characteristic of Chlamydia. These symptoms may be transient.

Urethritis in a woman may be asymptomatic or indistinguishable from cystitis or vaginitis. It may manifest as urinary tract infection (UTI) symptoms with a low concentration of bacteria on urine culture or tenderness localized to the distal periurethral area of the anterior vaginal wall. Female patients may not be able to distinguish urethral discharge from vaginal discharge. In addition to increased vaginal discharge, women who develop cervicitis may have intermenstrual bleeding, especially postcoital spotting or dyspareunia and cervical friability.

What To Do:

Obtain a sexual history that includes number of contacts, gender of contacts, anal/oral practices, and symptoms or illnesses in partners. Determine the color, consistency, and quantity of any discharge as well as any accompanying symptoms, such as genital or abdominal discomfort and dysuria.

Examine the entire genital area for lesions, and check undergarments for discharge staining. Palpate testes and epididymides for any mass or tenderness, or, in the case of a female patient, perform a complete pelvic examination.

Have the male patient milk the ventral surface of his penis to produce any discharge at the urethral meatus. (If discharge is scant, this should be attempted 1 to 2 hours after last voiding.)

In men, obtain a Gram stain of any urethral discharge, looking for gram-negative diplococci inside white cells, which indicate gonococcal infection. (Their absence does not rule out the possibility.) Urethritis in men is confirmed by any of the following:

The presence of mucopurulent or purulent discharge

Five or more white blood cells (WBCs) per oil-immersion field on a Gram stain of urethral secretions

Ten or more WBCs per high-power field on microscopic examination of first-void urine

Positive leukocyte esterase test on first-void urine

In female patients, order a urine or blood test to rule out pregnancy.

Examine the urine sediment for swimming protozoa, implying infection with Trichomonas vaginalis, best treated with metronidazole (Flagyl), 2 g PO once or 500 mg bid 7 days.

Endocervical swabs from women and urethral swabs or urine specimens from men can be used to detect Chlamydia trachomatis and Neisseria gonorrhoeae by using nucleic acid amplification tests (NAATs). NAATs do not require viable organisms, they are substantially more sensitive than previous tests, and the same specimen can be used to test for both organisms. When a NAAT is not available or not economical, nucleic acid hybridization assays can be used to detect C. trachomatis or N. gonorrhoeae. The Gen-Probe PACE 2 (Gen-Probe, San Diego, Calif.) and the Digene Hybrid Capture II (Gen-Probe) assays can detect both organisms in a single specimen. These tests are less sensitive than NAATs.

Cultures can be performed when transport and storage conditions are conducive to maintaining the viability of N. gonorrhoeae and C. trachomatis, especially when an isolate is needed (e.g., sexual abuse or treatment failure) and for monitoring of antimicrobial resistance. Cultures for N. gonorrhoeae have a high sensitivity and specificity and low cost, whereas C. trachomatis cell cultures have a relatively low sensitivity at a relatively high cost.

Order a serologic test for established syphilis. Further antibiotic treatment is required if the rapid plasma reagin (RPR) or Venereal Disease Research Laboratory (VDRL) test is positive.

Empirical treatment must be considered in symptomatic patients whose behavior puts them at risk for sexually transmitted infections, those who may be lost to follow-up, and those who have a history of recent exposure to an infected partner, regardless of their symptoms. Dual treatment of C. trachomatis and N. gonorrhoeae should be provided when an empirical treatment is instituted.

Dual treatment is indicated for the initial management of urethritis or cervicitis unless a sensitive laboratory technology is used to rule out C. trachomatis and/or N. gonorrhoeae.

To treat N. gonorrhea, give ceftriaxone (Rocephin), 250 mg IM × 1, or cefixime (Suprax), 400 mg PO × 1, or cefpodoxime (Vantin), 400 mg PO × 1. To treat C. trachomatis, give azithromycin (Zithromax), 1 g PO × 1 or doxycycline (Doryx), 100 mg PO bid × 7 days. (Azithromycin provides prophylaxis for syphilis.) Alternate regimens include levofloxacin, 500 mg PO daily × 7 days, or ofloxacin, 300 mg PO bid × 7 days, or erythromycin base (ERYC), 500 mg PO qid × 7 days, or erythromycin ethylsuccinate (EES), 800 mg PO qid × 7 days.

To treat recurrent and persistent urethritis, give metronidazole (Flagyl), 2 g PO × 1, or tinidazole 2 g PO × 1, plus azithromycin, 1 g PO × 1. Patients should be instructed to refrain from sexual intercourse until 7 days after therapy is completed.

Treat sexual partners of patients known or suspected to have a sexually transmitted infection with the same antibiotic regimen. (Cultures may be omitted.) These patients should refer all sexual partners within the preceding 60 days for evaluation and treatment; a specific diagnosis may facilitate partner referral. Some physicians feel comfortable providing a prescription for partner therapy, recognizing the limitations on partner referral.

Federal and state reporting regulations should be followed, with subsequent tracking of sexual contacts by state infection control boards.

Patients should be instructed to return if symptoms persist or recur.

Test-of-cure is not recommended as a routine procedure after therapy for C. trachomatis or N. gonorrhoeae infection with first-line Centers for Disease Control and Prevention (CDC)– recommended treatment regimens, except after C. trachomatis therapy during pregnancy.

Instruct the patient on the correct use of the condom to prevent reinfection.

What Not To Do:

Do not perform gram-stain testing for N. gonorrhoeae infection among women. The sensitivity of endocervical specimens is lower than that of urethral specimens from men with symptomatic gonorrhea, and adequate specificity requires a skilled microscopist.

Do not send off a serologic test for syphilis without following up on the results.

Discussion

Common causative organisms for urethritis and cervicitis are N. gonorrhoeae and C. trachomatis. Ureaplasma urealyticum, Mycoplasma hominis, M. genitalium, and Trichomonas vaginalis also are implicated in these clinical conditions. Although they are easily eradicated if treated early, some of these infections have been linked to serious reproductive health consequences; more systemic effects, such as disseminated gonococcal infections and Reiter syndrome; and facilitation of human immunodeficiency virus (HIV) transmission.

N. gonorrhoeae, a gram-negative diplococcus, is a major cause of pelvic inflammatory disease (PID), ectopic pregnancy, and infertility. C. trachomatis, an obligate intracellular bacterium, is the most common sexually transmitted bacterial pathogen in the United States and worldwide and is a leading cause of PID. The prevalence of both infections is higher among ethnic minorities and the poor. Age-specific rates are highest among girls and women 15 to 24 years of age and men 20 to 24 years of age. Both Ureaplasma and Mycoplasma have been isolated in cases of PID and nongonococcal urethritis (NGU). Recent studies have reported serious consequences of trichomoniasis, including increased perinatal mortality and increased HIV transmission. There is increasing evidence that T. vaginalis is a common cause of NGU in men.

Infections at any one site of the genitourinary tract produce poorly localizing symptoms, particularly in women, which may result in delayed diagnosis or misdiagnosis. Failure to recognize the causal relationship between symptoms of dysuria and sexually transmitted infections by patients and clinicians often results in failure to seek timely diagnosis and treatment. Longer duration and more gradual onset of dysuria may suggest C. trachomatis infection, whereas sudden onset of symptoms and hematuria suggests bacterial infection.

Disseminated gonorrhea with arthritis and dermatitis presents with fever, chills, and migratory polyarticular arthritis; a characteristic petechial necrotic pustular or tender papular rash of the distal extremities; and tenosynovitis of extensor tendons of the hands, wrists, or ankle tendons. This represents a more serious infection requiring a more comprehensive evaluation, extended parenteral antibiotic therapy, and hospitalization for all but the mildest cases.

Reiter syndrome is a triad of arthritis, urethritis, and conjunctivitis with associated skin lesions. The pathogenesis is unclear, but C. trachomatis has been implicated strongly along with other bacterial organisms. Treatment of Reiter syndrome consists of antimicrobial therapy against Chlamydia, NSAIDs, steroid injections of the affected joints, and topical steroids for uveitis.